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Application of outpatient cardiac testing among emergency department patients with syncope
  1. Olivia G Cook1,2,
  2. Muhammad A Mukarram2,
  3. Soo-Min Kim2,
  4. Kirtana Arcot2,
  5. Marie-Joe Nemnom2,
  6. Monica Taljaard2,3,
  7. Marco L A Sivilotti4,5,
  8. Brian H Rowe6,
  9. Venkatesh Thiruganasambandamoorthy2,3,7
  1. 1 Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
  2. 2 Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  3. 3 School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
  4. 4 Department of Emergency Medicine, Queen’s University, Kingston, Ontario, Canada
  5. 5 Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, Ontario, Canada
  6. 6 Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, Alberta, Canada
  7. 7 Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
  1. Correspondence to Dr Venkatesh Thiruganasambandamoorthy, Clinical Epidemiology Unit, The Ottawa Hospital Research Institute, Ottawa, Ontario K1Y 4E9, Canada; vthirug{at}


Objectives 2.6% of ED syncope patients will suffer cardiac serious adverse events (SAEs) within 30 days of disposition, and outpatient cardiac testing can improve patient safety. The objective is to determine whether outpatient cardiac testing for ED syncope patients is being appropriately ordered after discharge. To this end, we describe the proportion of high-risk and non-high (low and medium)-risk ED syncope patients as per the Canadian Syncope Risk Score (CSRS) who have a SAE after ED discharge, and the proportion referred for outpatient cardiac testing.

Methods Our multicentre prospective cohort study enrolled adult syncope patients between 2010 and 2014 in five academic EDs. We collected patient characteristics, disposition, CSRS predictors, outpatient referrals and testing results (Holter, echocardiography), and 30-day adjudicated SAE (death due to unknown/cardiac cause, myocardial infarction, arrhythmia and structural heart disease). We used descriptive statistics (mean, SD) to report our results.

Results Of 3584 enrolled patients (mean age 50.9 years, 57.7% women), 800 patients (22.3%) received an outpatient referral. Of these 800 patients, 40.3% of the non-high-risk patients (305/756) and 54.5% of the high-risk patients (24/44) received outpatient cardiac testing. Of all patients who received cardiac testing, five (1.5%; 95% CI 0.6% to 3.5%) suffered outpatient SAE (60.0% arrhythmias). Of all patients who did not receive cardiac testing, four patients (0.9%; 95% CI 0.3% to 2.2%) suffered SAE (all arrhythmias). Of the 20 (45.5%) high-risk patients who did not receive testing, two patients (10.0%; 95% CI 2.8% to 30.1%) suffered arrhythmias outside the hospital, while among the 451 (59.7%) non-high-risk patients, only two (0.4%; 95% CI 0.1% to 1.6%) suffered outpatient arrhythmias.

Conclusion Outpatient cardiac testing is largely underused, especially among high-risk ED syncope patients. Better guidelines for outpatient cardiac testing are needed, as the practice is highly variable and mismatched with patient risk.

  • emergency department

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  • Contributors VT, OGC, MLAS, BHR and MT conceived the idea. All authors contributed to the study design and research funding application. OGC, VT, MLAS, BHR, MAM and S-MK supervised the conduct of the trial and data collection, and undertook recruitment of patients. VT, MAM, S-MK, KA and MT managed the data, including quality control. KA and MT provided statistical advice on study design and analysed the data. OGC and VT drafted the manuscript. All authors reviewed the manuscript and contributed substantially to its revision. OGC and VT take responsibility for the paper as a whole.

  • Funding The study was funded by the Physicians’ Services Incorporated Foundation (PSI), Innovation Fund for Academic Health Sciences Centres of Ontario through The Ottawa Hospital Academic Medical Organization (TOHAMO), Canadian Institutes of Health Research (CIHR) and the Cardiac Arrhythmia Network of Canada (CANet) as part of the Networks of Centres of Excellence (NCE).

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Ottawa Health Sciences Network Ethics Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.